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MURRYSVILLE ALLIANCE CHURCH
LIABILITY RELEASE

Every activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By signing this form, the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related social activities. They also agree not to hold this church, its employees or volunteer assistants liable for damages, losses, or injuries to the person or property undersigned. The parents or guardians understand that they are signing a liability release for the minor listed on this form.

NOTE: You will need to complete a Medical Release Form if (1) you did not complete a Medical Release Form for the current year for the child named on this Liability Release or (2) your medical insurance information has changed since completing the Medical Release Form for the current year for the child named on this Liability Release.

Activity:_______________________________________________________________________

Date(s) Valid: ____________________________________________

Name of Minor:(Under 18)______________________________________________

Parent or Guardian's Signature: ________________________________________

Date:__________________________________

MURRYSVILLE ALLIANCE CHURCH
Medical Release Form

Name: ______________________________________________________________

Birthdate:________________________________________________

Name of Parent/Guardian: _________________________________________________

Address: ________________________________________________

City: State: Zip: Phone: __________________________________________________________

In Emergency, contact: ______________________________________________________

Phone/ Pager/Cell Phone: ______________________________________________________

Name of Doctor: Phone: _______________________________________________________

Name of Dentist: Phone: ______________________________________________________

HEALTH HISTORY

Allergies:
( ) Insect Stings ( ) Drugs ( ) Other

Other Conditions:
( ) Heart condition ( ) Frequent colds
( )Chronic asthma ( ) Frequent upset stomach
( ) Hay fever ( ) Epilepsy
( ) Diabetes ( ) Physical handicap
( ) Other:

If you checked any of the above, please give details (i.e. include normal treatment of allergic reactions):

Date of last tetanus shot: ________________

Name and dosage of any medications: _______________________________________

Any swimming restrictions? Yes / No
Any activity restrictions? Yes / No

If yes, please specify restrictions: ______________________________________________________________________

Our church's insurance is only a secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is on a church-related activity.

Do you have health insurance? Yes/ No
If yes, please fill out the following:

Name of the insured: ______________________________________

Name of Insurance: ____________________________________________

Policy Number: __________________________________________________

Address of insurance company: ______________________________________________

Phone Number of insurance company: ________________________________________

Do you have a prescription plan? Yes/ No
If yes, name of pharmacy: ______________________________________________

Phone number of pharmacy: ____________________________________________

"In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and/or administer an injection, anesthesia, or surgery for my son or daughter as deemed necessary."

Signature of Parent or Guardian: __________________________________________________________
Date: ________________________

THIS FORM VALID FROM April 2007 until Dec. 2008.